Australian Capital Territory
The ACT's public hospitals use the RiskMan general incident reporting system for clinical incident reporting. The system captures blood and blood product related incidents including near misses. The reported incidents are classified using an incident outcome rating (IOR). The IOR is based on the severity of outcome and has five ratings for clinical incidents:
- Extreme: Patient death
- Major: Major and permanent loss of function
- Moderate: Temporary loss of function
- Minor: Minor injury
- Insignificant: No injury.
Extreme incidents include sentinel events. A significant incident is an incident with an extreme or major outcome occurring in relation to Health Directorate services and care. Significant incidents require escalation.
The ACT's hospitals also participate in the STIR Program for national haemovigilance reporting. The IOR aligns with the clinical outcome severity defined in ANHDD (Table 46).
| Clinical outcome | ANHDD |
|---|---|
| Extreme | Death |
| Major | Life threatening Severe morbidity |
| Moderate | Minor morbidity |
| Minor | Minor morbidity |
| Insignificant | No morbidity |
Reporting requirements for incidents
Significant incidents
- All significant incidents must be notified verbally to the Director General within 12 hours and an electronic incident report must be submitted through RiskMan within 1 working day of the incident occurring.
- All significant incidents undergo an in depth investigation by or after consultation with the Health Directorate's HealthCARE Improvement Division.
- A copy of the initial significant incident report will be sent to the relevant Executive Director.
- The Director General and/or Deputy Director General may provide feedback when a report is submitted.
Other incidents
- RiskMan is the electronic incident reporting system available to and accessible by all staff within ACT Health for notifying incidents. Staff are encouraged to notify incidents as soon as possible and practical following the incident.
- Managers are responsible for reviewing all incidents submitted by staff who report to them within 5 working days, undertaking local actions in a timely manner, and documenting these in RiskMan.